Aggressive surgery for incisional hernia with necrotizing soft tissue infection highlighting unique abdominal findings.

Background: Surgery for incisional hernias with obesity can be more challenging because obesity is associated with perioperative complications. Necrotizing soft tissue infection (NSTI) is a life-threatening condition that requires aggressive surgical management. Few incisional hernias with NSTI have been reported, and the optimal strategy is undetermined. Case Presentation: A 66-year-old obese woman had been diagnosed with incisional hernia 4 years previously but was not treated. She presented with abdominal pain that had worsened 2 weeks previously. Emergency radical surgery was carried out for an incisional hernia with NSTI. The abdominal fascia was sutured directly without mesh. Negative pressure wound therapy was performed after surgery. The postoperative course was uneventful, without recurrence. Conclusions: Aggressive surgery is a valid strategy for life-threatening incisional hernias with NSTI. Strategies should be developed based on physiological and anatomical findings.

Radical surgery for intractable thoracic empyema complicating traumatic pneumothorax and rib fractures.

BACKGROUND: Few cases of traumatic pneumothorax complicated by thoracic empyema have been reported. The indication of antibiotic prophylaxis administration for traumatic pneumothorax during tube thoracostomy remains controversial, and thoracic injury complicated by empyema can be life-threatening and intractable. CASE PRESENTATION: A 42-year-old male patient was injured during a collision with a passenger car while driving a motorcycle. The patient (body mass index, 37 kg/m2) was diagnosed with right first-to-sixth-rib fractures without a flail segment, right clavicle fracture, and slight hemopneumothorax. Tube thoracostomy was performed for traumatic pneumothorax on day 3 without antibiotic prophylaxis. The patient demonstrated a progressive displaced rib fracture complicated by empyema on day 11. Radical surgery was performed for the empyema with rib fixation on day 15. The postoperative course was uneventful, and the patient was discharged from the hospital on day 31. CONCLUSIONS: A traumatic pneumothorax can be complicated by empyema. Thoracic injuries complicated by empyema can be life-threatening and intractable. Antibiotic prophylaxis for traumatic pneumothorax with tube thoracotomy should therefore be considered in select cases. The strategy for thoracic injury requires the assumption of an occult thoracic infection and chest wall instability.

Pediatric blunt abdominal trauma with horizontal duodenal injury in school baseball: A case report.

RATIONALE: Pediatric sports injuries, including those from baseball, most often are musculoskeletal injuries and rarely include blunt abdominal injuries. Duodenal injury is rare and often associated with other organ injuries. Because it has a relatively high mortality, early recognition and timely treatment are needed. Here, we report a case of successful treatment of a pediatric patient with duodenal injury incurred in the context of school baseball. PATIENT CONCERNS: A 13-year-old boy suffered blunt abdominal trauma and a right-hand injury caused by beating his abdomen strongly with his own right knuckle after he performed a diving catch during a baseball game. On the following day, the abdominal pain had worsened. DIAGNOSES: Computed tomography led to a suspicion of injury to the horizontal part of the duodenum. INTERVENTIONS: The duodenal injuries were repaired by simple closure. On the 10th post-operative day, an abscess formed in the retroperitoneal cavity because of an occult pancreatic injury. Ultrasound-guided percutaneous drainage of the cavity was performed. OUTCOMES: The post-operative course of the abscess drainage was uneventful. The patient was discharged from our hospital on day 72 after admission and was in good health at the 9-month follow-up. LESSONS: Regardless of the type of injury, we must assess the life-threatening conditions that can be expected based on the mechanism of the injury. In duodenal injuries, it is critical to perform surgical procedures and post-operative management based on the assumption of injuries to other organs.

Current state of drug analysis in Japanese emergency departments: a nationwide survey.

AIM: In 1999, the Japanese Society for Clinical Toxicology proposed 15 toxicants that would be useful for analysis: methanol, barbiturates, benzodiazepines, bromovalerylurea, tricyclic acid, acetaminophen, salicylic acid, theophylline, organic phosphorus pesticides, carbamate pesticides, glufosinate, paraquat, arsenic, cyanide, and methamphetamine. We aimed to reveal the current state of drug analysis for acute poisoning in the emergency department of Japanese hospitals. METHODS: From 1 April, 2017, we undertook a questionnaire survey in the emergency departments of 546 hospitals designated as educational institutions for emergency physicians. RESULTS: Responses were obtained from 246 hospitals (45.1%). Among drug abuse screening kits for qualitative testing, 80.9% used the Triage Drugs of Abuse Panel and 7.3% used Instant-View M-1. Analytical results have always been immediately obtained by 2.8% of facilities for methanol, 19.5% for barbiturates, 2.4% for benzodiazepines, 0.8% for bromovalerylurea, 1.2% for tricyclic acid, 12.2% for acetaminophen, 4.1% for salicylic acid, 44.3% for theophylline, 2.0% for organic phosphorus pesticides, 1.6% for carbamate pesticides, 1.2% for glufosinate, 2.4% for paraquat, 0.8% for arsenic, 1.2% for cyanide, and 1.2% for methamphetamine. CONCLUSION: In the treatment of acute poisoning, drug analysis is important for both clinical judgment and academic verification. However, many of the 15 toxicants proposed to be useful for analysis in 1999 are not yet immediately analyzed in the emergency department of Japanese hospitals. Furthermore, it is necessary to develop inexpensive testing systems and to provide insurance points for testing so that analysis can be carried out by emergency departments.

Clinical characteristics of stonefish "Oni-daruma-okoze" envenomation in Japan.

AIM: Stonefish, known in Japan as "Oni-daruma-okoze" (Synanceia verrucosa Block et Schneider), inhabit the waters surrounding the Okinawa/Amami districts. By far, habubites have been limited to these areas mainly due to climatic conditions. Due to changes promoted by global warming and increasing tourism, concerns regarding the potential for stonefish envenomation as well as jellyfish stings on the main island of Japan are increasing. However, few studies of stonefish envenomation have been reported in Japan. The current study aimed to comprehensively examine for the first time the clinical characteristics of stonefish envenomation in Japan. METHODS: We administered retrospective questionnaire surveys between January 2013 and December 2017 to determine patient characteristics, treatment, and clinical outcomes of stonefish envenomation. We compared patient characteristics between tourists and non-tourists. RESULTS: Over the 5-year study period, 15 patients were identified from four hospitals. More than 70% of stonefish envenomation cases occurred in the northern part of Okinawa Main Island. All patients recovered well, including four patients with severe stonefish envenomation. In two severe cases, the length of hospitalization was more than 1 week (8-9 days). Antivenom was not given. There were no significant differences between tourists and non-tourists with regard to baseline characteristics. CONCLUSIONS: During a 5-year period, 15 cases of stonefish envenomation occurred in Japan. The patients recovered well without treatment with antivenom.

Clinical characteristics of jellyfish stings in Japan.

AIM: Jellyfish known as "habu-kurage" (Chironex yamaguchii) inhabit the waters surrounding Okinawa and Amami, Japan, and jellyfish stings are limited to areas outside the Japanese main island. However, the shifts promoted by global warming and increasingly intensive interactions with people have led to concerns regarding the possibility of increased jellyfish stings on the main island of Japan. Similar concerns are being raised all over the world. However, studies examining clinical characteristics of jellyfish stings have been limited to Australia, the USA, Europe, and South-East Asia. Thus, this study aimed to examine for the first time the clinical characteristics of jellyfish stings in Japan. METHODS: We undertook retrospective questionnaire surveys from January 2013 to December 2017 to determine patient characteristics, treatment, and clinical outcomes. We compared patient characteristics between tourists and non-tourists. The primary end-point of the present study was to clarify the clinical characteristics of jellyfish stings. RESULTS: Over the 5-year study period, 204 patients were identified from eight hospitals based on the basic questionnaire, and 35 patients with moderate-to-severe jellyfish stings were also identified. All patients recovered well, including five patients with severe jellyfish stings. Antivenom was not given. The time intervals from the occurrence of jellyfish stings to hospital arrival significantly differed between tourists and non-tourists (P = 0.049), and all tourists visited the emergency department (P = 0.009). CONCLUSIONS: Approximately 40 cases of jellyfish stings occurred annually in Japan between 2013 and 2017. Patients recovered well without the use of antivenom.